I am a family physician practicing in Toronto, Ontario. I will be implementing an Electronic Medical Record in my practice, starting in March 2006. This blog is a diary of what happened.

Friday, December 15, 2006

Insurance companies

I dislike insurance companies. At times, it seems like their purpose is to make family physicians' lives miserable by inundating us with time consuming, difficult to fill, paper forms (multi-axial diagnoses; precise time of return to work; lenthy functional enquiries; detailed descriptions of amount of weight that a patient is able to lift; repeated requests for the same data, etc). I have noticed that, for the past several years, they are refusing to pay for the forms they request. Often, the request is urgent, detracting from patient care.

I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.

I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.

What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.

The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.

The only way to deal with these companies is through the political process. As individual physicians, we really have no say.

However, I have been talking with a local large health care corporation, and have let them know how dissatisfied I am with the current insurance processes (ineffective, inefficient, and with a possibly fraudulent billing mechanism--asking for the report while refusing to pay for it). The timeline for us to complete the forms ("do them this week or your patient loses pay and benefits") is certainly abusive. They know that I am now electronic, and they have pledged to review the process.

ICD9? Should it be now ICD-10-CA adopted by Canada since 2001? This is the Canadian standards for diagnoses to use per CIHI. Why is'nt the company providing the emr software using the updated revision? If we are going electronic all across Canada, it should adopt the current Canadian standards and make it relevant across the country.

ICD 10 is used by hospitals for reporting to CIHI (Discharge Abstract Database). They have CIHI coders to do this. It is not used by provincial governments for billing by physicians. They use ICD 9, so physicians are familiar with ICD 9.

The software company has included ICD9 (3 digit), ICD 9 (5 digit), ICD 10 and ICPC in the application. I think the only thing that most physicians are going to use is the ICD9 billing version in their province. That's what I did.

I know it's a patchquilt system; we need a consistent coding system for everyone to use. It will probably be SNOMED. I don't know how that will work in practice; probably "behind the scenes" software to translate ICD9 from physician EMRs and ICD10 from hospitals into SNOMED. Eventually, it will need some intelligent programming to put natural language charting into SNOMED codes.

Having coded 1500 charts in my practice, I can tell you that nothing but ICD9 would have worked for me. I was familiar with the codes, and tried to be consistent so I could audit later.

I went grocery shopping at Loblaws yesterday; the check-out clerks code everything that is not bar-coded. That is how Loblaws keeps track of things. They know how many lbs of bananas they sell. In our health care system, we often don't even know what our patients died of. Not acceptable.

We have to figure out how to talk the same language; the first step is to code on-going medical conditions consistently. Practically, that means using ICD9 in the CPPs of EMRs and not free text.

I can understand your frustration, however I work for a life insurance company and guess what our biggest frustration is doctors procrastinating on completing APS. You complain about filling these forms out but just so the public knows the insurance companies pay upwards of $300 for these forms. Sounds like fair compensation for a few minutes of your time. I have recently waited 4 months for a doctor to fill out an APS. Now if that client died during the process I hope you understand that you as the procrastinating doctor could be liable for the death benefit. Just fill out the damn form in a timely fashion, collect the money and quit making excuses or find another profession. excuses